IB-10 Rev. June 10, 2011
1
M e d i c a l R e l e a s e F o r m f o r
R o t a r y Y o u t h E x c h a n g e
I, ________________________________________________, am the parent or legal guardian of
___________________________________________________ (hereinafter “my child”).
For purposes of this medical release form only: the term “Youth Exchange” shall mean the Rotary
Youth Exchange Program that is organized by Rotary International through its Districts; and the term “Rotary
Youth Exchange Support System” shall mean the District 6840 Rotary Youth Exchange Committee, the
Rotary Youth Exchange Officer and Rotarian Counselor for my child’s host Rotary Club, other officials and
administrators in the United States who are responsible for the organization and administration of Rotary Youth
Exchange, and the host mother and host father for my child in the United States.
I give my consent and authority for the Rotary Youth Exchange Support System to take action to
help insure the safety, health, and welfare of my child. I also request and empower the Rotary Youth
Exchange Support System to authorize medical personnel and hospitals to provide appropriate medical care,
including but not limited to hospital tests, emergency surgical care, pathology, radiology and anesthesia, surgery
and prescriptive drugs for the health of my child. I further authorize these individuals to serve as my child’s
HIPAA Personal Representative for purpose of receiving medical information and communicating with medical
providers about my child’s medical condition.
The child covered by this authorization is:
Full Name Date of Birth
Home Address
City/State/Zip
Home Phone
In Case of Emergency during the Rotary Youth Exchange contact:
Name
Home Phone Business Phone
Cell Phone e-mail
Medical/Health Problems:
1. Allergies y n
2. Asthma/Respiratory y n
3. Vision/Hearing y n
4. Surgery y n
5. Heart Problems y n
6. Diabetes y n
7. Seizures/Epilepsy y n
8. Headaches y n
9. Stomach y n
10. Broken Bones y n
11. Other y n
If your answer was “yes” to any of the above questions, please explain below, including a number reference: